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Grand Challenges is a family of initiatives fostering innovation to solve key global health and development problems. Each initiative is an experiment in the use of challenges to focus innovation on making an impact. Individual challenges address some of the same problems, but from differing perspectives.

Maria do Carmo Leal from Fiocruz in Brazil will undertake a pilot “Parto Adequado” (Adequate Birth) project to evaluate whether different health care models offered by medical institutions during pregnancy and childbirth can promote healthier births, particularly by reducing the rate of unnecessary medical procedures. These include caesarean section without clinical indication, which occur frequently in Brazil and can have negative consequences. They have selected 23 geographically dispersed hospitals for the pilot study, which will involve around 16,000 mothers. To promote good practices, they have developed three health care models that combine different numbers and types of medical staff (i.e., Doctors and nurses-midwives) to be involved at specific stages from pregnancy to birth. These will be offered to hospitals for implementation over 18 months. They will then analyse the degree of implementation of the models, and their effects on the type of birth, adoption of good practices, and hospital costs after two and three years. They will also interview the mothers and health care workers to evaluate acceptability of the different models.

Marcos Augusto Bastos Dias from Fiocruz in Brazil in collaboration with the Global Pregnancy Collaboration (CoLab) will test a new approach for managing women in Brazil with preeclampsia in order to reduce unnecessary preterm births. Preeclampsia is characterized by high blood pressure and impaired organ function during pregnancy and can cause severe complications or even death for mother and child. The only cure is delivery, but preterm births are also high risk. In Brazil preeclampsia accounts for far more preterm deliveries than in higher income countries who more readily choose medication to reduce the severity of the disease, and help delay delivery. The study includes seven geographically diverse hospitals with 23 satellite community health centres over four years. They will train staff to adopt the WHO guidelines for preventing preeclampsia and introduce a method for identifying low-risk women whose pregnancies can be safely prolonged. The study will also generate data and biological samples that can be used to help better stratify risk and understand the disease, which could further improve clinical management and lead to new treatments.

Sonia Isoyama Venancio from the Instituto de Saúde in Brazil will implement a program for monitoring the development of children less than five years of age during vaccination campaigns in the municipalities, to help identify risk factors, raise awareness, and support healthy development. They will design and pilot test a questionnaire that can be easily applied during a vaccination procedure to carefully query the health and behavior of the child, as well as their family environment and access to health services and education. To promote implementation of the program, they will recruit and train interviewers, and partner with Universities to recruit health-care students for collecting the data and entering them into a custom built web application. They will validate their approach for identifying children with developmental problems, and analyze the data for potential causes such as socioeconomic conditions and quality of health care.

Ricardo Tavares Pinheiro from the Universidade Católica de Pelotas in Brazil will identify factors that are associated with gestational depression, and determine whether they influence their response to treatment and ultimately the healthy development of the child. Gestational and postpartum anxiety and depression affect 15-25% of mothers and can alter the emotional, social and cognitive development of the child. They are likely caused by a complex combination of genetic, hormonal, psychological and social/environmental factors. Only a handful of risk factors, including the levels of proinflammatory molecules, have been identified. The study will involve around 1250 pregnant women who will be evaluated by psychologists to ascertain their mental state. Blood and buccal cell samples will be collected to analyze the presence of candidate risk markers (specific proteins and microRNAs) and genetic polymorphisms (specific DNA sequences) to identify those associated with depression. They will also determine the relationship between these psychological and physiological factors and the subsequent motor and neurocognitive development of the born children. Clinical studies will also evaluate the efficacy of several modified therapeutic approaches centered on cognitive behavioral therapy, which involves guiding the patient to modify any distorted thinking and can be effective in depressed mothers.

Rita de Cássia Silveira from Hospital de Clínicas de Porto Alegre in Brazil will develop and test a program for families with preterm infants to follow at home to improve the child’s cognitive, motor and social development. Preterm infants (those born with less than 37 weeks of gestation) can suffer a variety of complications due to incomplete brain, lung and eye development, which can cause long-term problems. They have shown that careful baby massage, alongside the standard skin-to-skin care by the mother, in the hospital after birth can improve the child’s neurological development at two years of age. Here they will perform a randomized study of around 80 mothers of preterm infants, and teach one group to perform the massage technique and instruct them to administer it at home for the child’s first 12 months of life, which will be carefully monitored. The effects on motor and neurodevelopment will be assessed at regular intervals up to 24 months of age and compared to a control group performing only skin-to-skin care.

Iná da Silva dos Santos from the Universidade Federal de Pelotas in Brazil will develop a simple, low-cost strategy targeting mothers to ensure young children get enough sleep. Inadequate sleep is more common in children from low-resource households, and can negatively impact their physical and mental health, including their cognitive development. Children can be encouraged to sleep well by creating a restful environment and helping them learn to get to sleep by themselves. They will perform a randomized controlled study with around 500 mothers of infants aged three months. One group of mothers will be taught about normal sleep behavior during the first year of life and how to encourage their child to sleep. The effect of this intervention on sleep duration, growth and neurodevelopment will be analyzed over a 24-month period. Sleep duration will be monitored by actigraphy to ensure accuracy.

Mauricio Lima Barreto from Fiocruz in Brazil will evaluate the impact of social and economic inequalities, and the national family allowance program (Bolsa Familia), on healthy births and early childhood health and development. They will setup a cohort, which will be derived from a central database of named households created to support Brazil’s social programs, and a data center for the analysis. They will use a variety of demographic, economic and social data on families, as well as information on births and childhood deaths, and child growth. The impact of receiving family allowance, and the effect of its value and duration, on outcomes such as birth weight, prematurity, fetal death, and early childhood growth will also be measured. This approach will generate evidence to help maximize the value of the social program and inform future related policies.

Guilherme Vanoni Polanczyk from Universidade de São Paulo in Brazil will test their new method Pixel Averages for Auxological Assessment (PIXA3) that enables parents at home to frequently and precisely measure height during early childhood to help better detect and monitor growth defects in low-resource settings. The current standard for accurately measuring height requires specialized equipment and trained staff, and is thus unsuitable for frequent application. Their new method involves using a smartphone to take multiple photographs of an individual next to an internal standard of known size, and doesn’t require cross-sectional population norms, which have complicated current methods of longitudinally assessing growth. They will perform a randomized controlled trial in São Paulo to test the feasibility of their method and determine how accurate it is compared to traditional growth measures taken at a health clinic.

Maria Conceicao do Rosário from Universidade Federal de São Paulo in Brazil will assess the effect of mother and teacher support programs in pre-schools in poor districts of São Paulo on the physical and emotional well-being of families, and on early childhood development. Many poor communities in Brazil suffer from high levels of urban violence and adult mental illness that affect the healthy development and well-being of children. Brazil has pledged that all children aged 4-6 will be in pre-school by 2016, presenting an opportunity to improve the quality of pre-school teaching to impact childhood development. They will recruit around 900 mothers to evaluate a mother support program, which will involve weekly group meetings for around 12 weeks to discuss issues including parenting methods and healthy child development. They will also implement a teacher support program to increase their knowledge on childhood health and development, and assess the impact on their attitudes and practices.